Definitions
Form used when a beneficiary is requesting reimbursement for out-of-pocket prescription claims.
Medicare Part D Prescription Claim Form
If contacted prior to 10/01 by an existing Medicare member who has received their upcoming plan package information: You are NOT PERMITTED to...
provide information about other plans not described in their plan’s ANOC/EOC and/or LIS Rider. Please apologize for the inconvenience and request that the member contact us on or after 10/01 for that additional information.
Phone number providers can call to discuss the decision of a prior authorization request for State of IL(X773J) members.
1-800-414-2386
Monthly cost member will pay for their covered medication.
$50
Which month contains the first day of Fall?
September
The prescription benefit plan provided to the Federal Government Employees.
Federal Employee Program (FEP)
ANOC packages will NOT contain:
Pharmacy Directory
Evidence of Coverage (EOC)
Formulary
Turn around time for standard coverage determinations is 3 business days. (True/False)
False (72 hours - This includes nights, weekends, and holidays.)
The BIN/PCN/Group of the Medicare GLP-1 Bridge
This traditional American fall dessert features a spiced, pumpkin-flavored custard baked in a pastry shell, often served at Thanksgiving
Pumpkin Pie
Determining if a member or insurance group member is entitled to the benefits for which they are requesting payment.
Eligibility Verification
Initial coverage cost share of a brand medication for a LIS Level 2 member in 2027
$5
Phone number for the IRE - C2C Solutions
833-919-0198
GLP-1 products purchased by beneficiaries through the Medicare GLP-1 Bridge program are eligible for Medicare Prescription Payment Plan. (True/False)
False
A festival that is celebrated in Germany during the fall season.
Oktoberfest
Price a wholesaler or drug supplier pays to the originating pharmaceutical manufacturer for the purchase of pharmaceutical products.
Wholesale Acquisition Cost (WAC)
Prescriptions filled at an out-of-network pharmacy are limited to a 30-day supply at the standard cost share, 1 full copay, when:
The prescription is for a medical emergency or urgent care.
The member is unable to get a covered drug in a time of need because there are no 24‑hour network pharmacies within a reasonable driving distance.
The prescription is for a drug that is out‑of‑stock at an accessible network retail or mail service pharmacy (including high‑cost and unique drugs).
If a member is evacuated or otherwise displaced from their home because of a federal disaster or other public health emergency declaration.
A vaccine or drug administered in a doctor’s office.
Complain that a drug is not covered, and the member NEEDS the medication (CD vs GRV)
Coverage Determination (CD)
The provider may request that the pharmacy send the claim directly to Medicare GLP1 Bridge and they must include ____ and ____ on the prescription in the Note field if electronic, or as an annotation if non-electronic.
An obesity diagnosis code
Indicating “SEND TO BRIDGE FOR WEIGHT MANAGEMENT”
A sticky version of sugar that is often a brown-ish orange color. Can be used on top of ice cream, fruits, inside candy bars, or eaten by itself.
Carmel
Medicare's _____ is a permanent program that provides immediate and retroactive Part D prescription drug coverage for eligible low-income beneficiaries who do not yet have prescription drug coverage.
Limited Income NET Program (LINET)
Is Part B cost-sharing eligible within the Medicare Prescription Payment Plan
NOT eligible
Time frame Coverage Determination can be renewed prior to expiring.
90 Days
Beneficiaries enrolled in ____ aren't eligible to participate unless they're also enrolled in a stand alone drug plan (PDP)
PACE
What marks the official start to the fall season in the Northern Hemisphere?
The autumnal equinox